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Imaging Sciences Interesting Cases

Case 73

Charles Hubeny, MD

Clinical Presentation: Patient is a 73-year-old female with occasional abdominal pain.

Imaging Findings: Paraesophageal hernia with organoaxial volvulus.
Figure 1. Right lateral view of the abdomen from an upper GI study demonstrates a large hiatal hernia with the GE junction posteriorly above the level of the diaphragm with the gastric fundus and body herniated adjacent to the esophagus.
Figure 2. AP overhead view of the abdomen from an upper GI study shows the hernia with organoaxial volvulus. The greater curvature of the stomach is superior to the lesser curvature
Figure 3. Axial CT slice shows the stomach behind the heart with GE junction posterior and above the diaphragm.

Diagnosis: Paraesophageal Hiatal Hernia

Discussion: A hiatal hernia is defined as protrusion of a part of the stomach through the esophageal hiatus of the diaphragm. It can be classified as either a sliding (axial) hernia or paraesophageal (rolling) hernia. The gastroesophageal (GE) junction and cardiac portion of the stomach pass through the hiatus into the thorax with a sliding hernia while the gastric fundus herniates into the thorax with the GE junction may be above or below the diaphragm. The stomach rotates on its longitudinal axis with fundal herniation thus making organoaxial volvulus a usual finding with paraesophageal hernias.

There are also four types of surgical classification:

Type 1:  GE junction and gastric cardia intrathoracic (sliding)
Type 2:  GE junction normal, gastric fundus intrathoracic (paraesophageal)
Type 3:  Both GE junction and fundus intrathoracic (paraesophageal)
Type 4:  GE junction and entire stomach intrathoracic (paraesophageal)

Symptoms can range from asymptomatic to excruciating abdominal pain. Triad of Borchardt from gastric volvulus includes severe abdominal pain, unsuccessful vomiting, and inability to pass an NG tube are typical severe symptoms. Prevalence increases with age with more females affected than males.

Since a paraesophageal hernia may strangulate, surgery is frequently recommended to prevent strangulation, even if the patient is asymptomatic. Those with severe pain are treated as a surgical emergency. An anterior gastropexy or gastrostomy may be used to correct gastric volvulus.

References:

  1. Eren S, Ciris F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 2005 Jun;54(3):448-59. [PubMed]